Compliance Program
The UW School of Dentistry is committed to conducting its business in compliance with the law. The School can meet this commitment only through the efforts of our department leaders and chairs, administrators, managers and their designees, faculty, staff and students. We must continue to earn the trust and respect of patients and others by conducting our daily affairs with honesty, integrity, and in compliance with the letter and spirit of all applicable laws. Although honesty and integrity are individual attributes, and each individual is ultimately responsible for his or her own conduct, the School is committed to maintaining a working environment that promotes these ideals and permits our employees to demonstrate the highest professional standards in performing their daily tasks.
The School is in the process of implementing its Compliance Program. Program Policies will be added to this site as they are finalized.
Compliance Program Policies
Compliance Program Introduction
The School has developed a Compliance Program as a comprehensive statement of the responsibilities and obligations of all employees, students and professionals, to understand and adhere to applicable federal and state laws, and to fulfill the program requirements of federal and state health plans. Compliance practices and procedures of the School will be developed and kept current with applicable laws and regulations.
Compliance Program Basic Principles
Integrity: The School honors integrity as a fundamental value and demonstrates the highest levels of professional conduct in all its dealings. Each individual associated with School must perform his/her personal duties in accordance with these values.
Compliance with Legal Standards: The School follows all applicable federal and state laws and regulations. Each person associated with the School is charged with the responsibility to learn and understand the legal standards which relate to his/her duties and to follow them accordingly.
Accurate Billing and Records: The School is committed to maintaining accurate documentation and billing records that reflect services provided. Errors will be assessed and corrected appropriately.
Compliance Program Structure
Participation: It is the responsibility of each faculty member, staff, student and independent contractor to abide by applicable laws and regulations and support the School’s compliance efforts.
Responsible Officer: The School has designated the Compliance Director as the individual within the School responsible for overall implementation and operation of the Compliance Program.
Compliance Committee: The School’s Compliance Oversight Committee will advise and assist the Compliance Director with implementation of the Compliance Program.
Oversight: The Compliance Director will report at least biannually to the Compliance Oversight Committee on the status of compliance within the School.
Employee and Vendor Screening: The School shall not contract with, employ or extend privileges to any individual or entity that is excluded from participation or is otherwise ineligible to participate in federal health care programs.
Education: The School will provide ongoing, effective education and training programs for all faculty, staff and students on Organizational Professionalism and the Compliance Program.
Auditing and Monitoring: The School will establish procedures for monitoring the effectiveness of the Compliance Program.
Risk Assessment: The School will conduct ongoing risk assessments and take appropriate steps to reduce the risk of law violation identified through the assessment process.
Enforcement and Prevention: Individuals violating the standards of this Compliance Program will be subject to progressive discipline, up to and including termination, if warranted. Sanctions will be applied in accordance with relevant staff personnel policies, School policies/procedures and/or faculty code as appropriate.
Organizational Response: The School will respond to potential violations of the Compliance Program and/or applicable federal and state laws/regulations reported by staff, students, faculty members or others that have questions or concerns regarding School activity.
Employee Participation and Reporting
Approval/Effective Date: 2/27/2008
Policy: It is the responsibility of every individual to abide by applicable laws and regulations and support the UW School of Dentistry’s compliance efforts. All staff, students and faculty members are required to promptly report their good faith belief of any potential violation of the Compliance Program or applicable law. The School will provide anonymity to the individuals who report concerns to the greatest extent possible under the circumstances. There will be no retaliation in the terms and conditions of employment as a result of such reporting.
Purpose: The purpose of this policy is to define the individual School staff, student and faculty member responsibilities for assuring ethical business practices and supporting the Compliance Program
Procedures: Individuals will report their good faith belief of violations of the Compliance Program or applicable laws and regulations via one of the following methods:
- written or oral report to a supervisor or anyone in a School leadership role
- contact the Compliance Director at (206) 543-5331 or tarafao@u.washington.edu or Box 356365
- call the School’s Compliance Hotline at (206) 685-5254
- contact UW Health Sciences Human Resources at (206) 543-9406 or Box 357250
All staff, student and faculty member reports of potential violations will be reviewed at the level determined appropriate. School leaders will ensure that the Compliance Director is immediately informed of any reported concern. Any retaliation for good faith reporting is strictly prohibited.
Responsible Officer
Approval/Effective Date: 2/27/2008
Policy: The UW School of Dentistry has designated the Compliance Director as the individual within the School responsible for overall implementation and operation of the Compliance Program. The Compliance Director officially reports to the Director of Administration and Finance.
Purpose: The purpose of this policy is to assign and communicate the responsibility for implementation and operation of the School’s Compliance Program.
Procedures:
The Compliance Director will be responsible for ensuring that:
1. Practices and procedures are reviewed and updated as necessary.
2. Staff, faculty and vendor screening mechanisms are in place and are operating properly.
3. Independent contractors and agents who furnish services to the School are aware of the requirements of the Compliance Program.
4. Staff, students and faculty are receiving adequate education and training and that such education and training is documented.
5. Internal compliance reviews and monitoring activities are conducted.
6. Staff, student and faculty complaints and other concerns regarding compliance are promptly investigated.
7. Adequate steps are taken to correct any identified problems and prevent the reoccurrence of such problems.
8. External sources of compliance issues are monitored and utilized as prompts for examining School activities.
Compliance Oversight Committee
Approval/Effective Date: 2/27/2008
Policy: The UW School of Dentistry Compliance Oversight Committee will be established to advise and assist the Compliance Director with implementation of the Compliance Program.
Purpose: The purpose of this Policy is to assign and communicate the responsibilities of the Compliance Oversight Committee for the Compliance Program at the School.
Procedures: The Compliance Director will report to the Compliance Oversight Committee biannually. This report will include the results of any recommendations from work conducted during the previous six months, and any other information requested by the Committee. A representative from the Attorney General’s Office will serve as an advisor.
SCHOOL OF DENTISTRY COMPLIANCE OVERSIGHT COMMITTEE
Members: Compliance Director, Director of Finance and Administration, Executive Director of Development, Alumni Relations and CDE, Director of Clinical Operations, Dean of Dentistry, Associate Deans, Faculty Council Chair, and Department Chairs.
Meetings: The committee will meet a minimum of biannually.
Role: The primary role of the Compliance Oversight Committee is to assist the Compliance Director by providing oversight, participating in strategy development, and assessing operational performance of the organization with respect to compliance. In performing this function, the committee will:
• Review concerns and assist with internal risk assessment activities
• Make policy decisions
• Participate in development of the compliance work plan
• Provide executive sponsorship of the work plan initiatives
• Allocate resources for work plan initiatives
• Track resolution of issues
Vendor Screening
Approval/Effective Date: 7/9/2008
Policy: The UW School of Dentistry shall not contract with any individual or entity excluded from participation or otherwise ineligible to participate in federal health care programs.
Additionally, if an individual or entity with whom the School currently contracts becomes excluded from participation in federal health care programs, the School shall immediately cease contracting with that excluded individual or entity.
Purpose:The purpose of this policy is to ensure that the School does not receive supplies or services from an individual or entity that has a history of engaging in illegal or improper activities. This policy also seeks to ensure the School does not enter into illegal or improper contract agreements.
Procedures:
1. This policy applies to the following categories of vendors:
• Suppliers
• Independent contractors
• Agency contract staff
• Consultants2. The School’s Department Administrators and Program Directors shall be responsible for ensuring that the non-excluded status of prospective vendors and contractors is determined through accessing the OIG List of Excluded Individuals/Entities on the OIG website (www.hhs.gov/oig), and the General Services Administration (GSA) website (www.epls.gov) when making purchases using their procurement Visa card (Procard) or under the direct buy limit of $3,000.
The UW Purchasing Department will be responsible for checking the non-excluded status of the vendors on all requisitions submitted through PAS.
3. Should a vendor or contractor appear on the OIG List of Excluded Individuals/Entities or the GSA website, the School shall not contract with that individual or entity until the issues are resolved and it is clear that the individual or entity is not excluded from participation in federal health care programs.
4. The School’s contracts with vendors and contractors will include language that obligates vendors and contractors to conform to the principles and standards of its compliance program. The following language is to be included in all contracts with individuals or entities:
Federal Exclusion Clause
Vendor represents and warrants that it is not excluded from participation, and is not otherwise ineligible to participate, in a “federal health care program” as defined in 42 U.S.C. § 1320a-7b(f) or in any other government payment program. In the event Vendor is excluded from participation, or becomes otherwise ineligible to participate in any such program during the Term, Vendor will notify the School of Dentistry in writing within three (3) days after such event, and upon the occurrence of such event, whether or not such notice is given to the School of Dentistry, the School of Dentistry reserves the right to immediately cease contracting with that excluded individual or entity.
If Vendor is an Employment Agency, Vendor represents and warrants that its employees are not excluded from participation in a “federal health care program” as defined in 42 U.S.C. § 1320a-7b(f).
Corporate Compliance Plan Clause
The University of Washington, School of Dentistry’s Compliance Program is designed to ensure that the School of Dentistry complies with federal, state, and local laws and regulations. It focuses on the promotion of good corporate citizenship, including a commitment to uphold the highest standard of professional and legal business practices and the prevention of misconduct. Vendor agrees to conduct all business transactions that occur pursuant to this Agreement in accordance with all applicable laws, regulations, and the School of Dentistry compliance policies, and ensure that Vendor officers, employees and agents do the same. Any major compliance violations would be considered a material breach of this contract.
